ASTHMA + TUE HISTORICAL PERSPECTIVE: Asthma + TUE <2004 WADA: abbreviated TUE for β2 agonist use 2004 WADA: Objective proof of AHR required for TUE for inhaled β2 agonist use (salbutamol, salmeterol, formoterol, terbutaline) 2010 WADA: Removal of TUE requirement for salbutamol (urinary thresholds) and salmeterol / 2 HISTORICAL PERSPECTIVE: Asthma + TUE < 2011: Declaration of Use for inhaled GC 2011: Declaration of Use no longer required for inhaled GC 2013: Formoterol: TUE only for doses > 54 mcg/d / 3 2014: one can still get a TUE for the prohibited β2 agonists if TUE criteria are fulfilled Prohibited Substances ASTHMA TUE • All oral/ intravenous β2 agonists REQUIREMENTS • All oral/ intravenous GC • Salbutamol (>1600mcg/ d) or (> 1000ng/mL in urine) • Formoterol (> 54 mcg over 24h) • Terbutaline • Procaterol + other LABA • **Salmeterol does not need a TUE!** / 5 Medical File to Support TUE Application ASTHMA TUE • Medical History REQUIREMENTS • Clinical Examination • Spirometry report, or • Bronchial Provocation Test • Treating Physician contact info. • Explanation as to why salbutamol, salmeterol or formoterol are not appropriate / 6 Objective criteria for granting of a TUE for β2 agonists Objective Test Criteria to be met for permission to use β2 agonists Spirometry Bronchodilator test ≥12% increase in FEV1 over baseline following inhalation of an inhaled beta 2 agonist Objective Test Criteria to be met for permission to use β2 agonists Bronchial Provocation Tests Eucapnic Voluntary Hyperpnea ≥10% fall of FEV1 Methacholine Aerosol challenge ≥20% fall of FEV1 - PC20<4mg/mL, [steroid naïve] or if taking inhaled GCS > 1 month, then PD20 should be less or equal to 1600 mcg or PC20 less or equal to 16.0 mg/mL Hypertonic Saline Aerosol 15% fall of FEV1 after inhaling or ≤22.5 ml 4.5% challenge saline Exercise Challenge Tests ≥10% fall of FEV1 (field or laboratory) Histamine Challenge ≥ 20% fall of FEV1 at a histamine concentration of 8mg/mL or less during a graded test of 2 minutes Dry Powder Mannitol Challenge 15% fall of FEV1 after inhaling ≤ 635 mg of mannitol ASTHMA TUE REQUIREMENTS TUE Validity • 4 years • Annual review by respiratory physician • ADO may impose other stipulations: – Shorter time frame – Review by respirologist / 9 RETROACTIVE TUE WADA IST 4.3 FULL DOCUMENTATION OF EMERGENCY SITUATION REQUIRED! « AN ATHLETE’S HEALTH SHOULD NEVER BE JEOPARDIZED BY WITHOLDING MEDICATION IN AN EMERGENCY » HEALTH IMPLICATIONS Sports physicians looking after endurance athletes should be educated in the presentation, diagnosis, treatment principles and TUE requirements for the management of asthma/ AHR. TUE IMPLICATIONS of all medical conditions we see in athletes this is the one that is now managed in a way that: • Respects the health of the individual • Respects the potential for ergogenesis Thank you! Audrey Kinahan + Margo Mountjoy Paris, October 2014 .